Background
-
Audit of diabetes care using the Alphabet Strategy as a template to determine the quality of diabetes care at various centres worldwide,
-
A qualitative questionnaire study to determine the feasibility of implementation of the Alphabet Strategy in various healthcare settings,
-
Pilot study of implementation of the Alphabet Strategy in India in a low resource setting.
Methods
Worldwide audit of diabetes care
Collection of data
Alphabet Strategy checklist template used in GAIAAdvice - weight, BMI, smoking statusBlood pressureCholesterol - lipid profile where availableCreatinine and microalbuminuria, or proteinuria where microalbuminuria is not availableDiabetes control by HbA1c, or fasting or post-prandial glucose where HbA1c not availableEye examination - evidence of fundus exam either by direct ophthalmoscopy or retinal photographsFoot examinationGuardian drug usage - aspirin, ACE inhibitor or angiotensin receptor blocker, statins
Statistical analysis
Quality Indicator | Maximum points† | ||
---|---|---|---|
General | 1 | General background data: register of all diabetes mellitus patients | 6 |
Advice | 2 | % whose notes record diabetes mellitus | 3 |
3 | % with record of smoking status | 3 | |
4 | % who smoke and a record that smoking cessation advice has been offered | 3 | |
18 | % who have had influenza immunisation in the preceding 1 Sep to 31 Mar | 5 | |
Blood pressure | 11 | % with a record of blood pressure | 3 |
12 | % whose last blood pressure is 145/85 or less | 17 | |
Cholesterol & creatinine | 16 | % who have a record of total cholesterol | 3 |
17 | % whose last total cholesterol is 5 or less | 6 | |
13 | % with a record of microalbuminuria testing | 3 | |
14 | % with a record of serum creatinine testing | 3 | |
Diabetes control | 5 | % who have a record of HbA1c | 3 |
6 | % with HbA1c of 7.4 or less | 16 | |
7 | % with HbA1c of 10 or less | 11 | |
Eyes | 8 | % who have a record of retinal screening | 5 |
Feet | 9 | % with a record of presence or absence of peripheral pulses | 3 |
10 | % with a record of neuropathy testing | 3 | |
Guardian drugs | 15 | % with proteinuria or microalbuminuria who are treated with ACE inhibitor (or ARB) | 3 |
Total points | 99 |
Questionnaire study
Collection of data
Data analysis
Implementation of the alphabet strategy in a non-high income country
Results
Worldwide audit of diabetes care
Serial number | Country | QOF score (out of 99) | GNI per capita 2005/06*† | GDP per capita/US$* | THE%* | LE/years* |
---|---|---|---|---|---|---|
GRE2 | Greece | 90.14 | H | 23506 | 9.7 | 79 |
JER | Jersey | 87.52 | H | 57000 | 8.1 | 80 |
FRA1 | France | 85.02 | H | 33819 | 11.1 | 80 |
SPA2 | Spain | 81.65 | H | 28025 | 8.3 | 81 |
IND10 | India | 80.56 | LM | 820 | 4.0 | 64 |
ENG | England | 78.95 | H | 40342 | 8.5 | 79 |
FAL | Falklands | 78.92 | H | 40342 | 8.5 | 79 |
FRA2 | France | 77.19 | H | 35457 | 11.1 | 81 |
AUS3 | Australia | 76.93 | H | 34149 | 8.4 | 81 |
NOR | Norway | 76.54 | H | 65767 | 9.1 | 80 |
SPA | Spain | 72.44 | H | 26056 | 8.3 | 80 |
AUS4 | Australia | 72.08 | H | 34149 | 8.4 | 81 |
AUS2 | Australia | 68.30 | H | 34149 | 8.4 | 81 |
GRE1 | Greece | 68.12 | H | 21621 | 9.6 | 79 |
IND1 | India | 66.79 | LM | 732 | 4.0 | 63 |
USA | USA | 66.40 | H | 42516 | 14.7 | 77 |
SAF1 | South Africa | 59.05 | UM | 5235 | 8.8 | 51 |
BAR | Barbados | 54.46 | H | 11109 | 7.0 | 76 |
IND8 | India | 53.48 | LM | 820 | 4.0 | 64 |
IND7 | India | 50.74 | LM | 820 | 4.0 | 64 |
MAL | Malaysia | 48.31 | H | 5286 | 4.1 | 73 |
IRE | Ireland | 45.69 | H | 48866 | 7.5 | 78 |
JAM | Jamaica | 41.29 | UM | 4263 | 4.1 | 71 |
GUY | Guyana | 37.74 | LM | 1949 | 6.0 | 68 |
WSA | Western Samoa | 37.21 | UM | 2287 | 5.5 | 71 |
IND9 | India | 36.59 | LM | 5468 | 8.5 | 64 |
SAF2 | South Africa | 36.59 | UM | 820 | 4.0 | 51 |
IND5 | India | 36.16 | LM | 732 | 4.0 | 63 |
BAN | Bangladesh | 35.71 | LM | 429 | 3.2 | 67 |
ZIM | Zimbabwe | 35.12 | L | 434 | 8.1 | 45 |
IND3 | India | 33.91 | LM | 732 | 4.0 | 63 |
STK | St. Kitts | 32.75 | H | 10394 | 5.4 | 71 |
GHA | Ghana | 32.42 | LM | 495 | 7.1 | 61 |
PER | Peru | 31.66 | UM | 3312 | 4.5 | 73 |
MAU | Mauritius | 30.05 | UM | 5054 | 4.6 | 72 |
GRN | Grenada | 29.26 | UM | 6804 | 6.4 | 75 |
IND4 | India | 29.20 | LM | 732 | 4.0 | 63 |
IND2 | India | 27.11 | LM | 732 | 4.0 | 63 |
SOL | Solomon Islands | 25.26 | LM | 881 | 4.6 | 65 |
GHA2 | Ghana | 19.70 | LM | 495 | 7.1 | 61 |
AUS1 | Australia | 19.66 | H | 34149 | 8.4 | 81 |
IND6 | India | 17.27 | LM | 732 | 4.0 | 63 |
EGY | Egypt | 16.16 | UM | 1209 | 5.2 | 72 |
BEL | Belize | 13.35 | UM | 3821 | 3.5 | 75 |
TON | Tonga | 10.16 | UM | 2573 | 4.7 | 71 |
Serial no. | Country | QOF score | NICE 9 | BMI* | Smoking* | BP* | TC* | Cr* | Microalb* | Urine prot* | HbA1c* | Eye* exam | Foot* exam |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|
GRE2 | Greece | 90.14 | 60 |
95
|
75
|
100
|
98
|
98
|
95
|
95
|
100
|
96
|
96
|
JER | Jersey | 87.52 | 74 |
96
|
94
|
91
|
92
|
90
|
86
| 54 |
98
|
90
|
93
|
FRA1 | France | 85.02 | 47 |
87
|
78
|
97
|
94
|
93
|
83
| 46 |
95
|
94
|
92
|
SPA2 | Spain | 81.65 | 6 |
92
| 8 |
96
|
98
|
88
| 61 | 6 |
95
|
88
|
86
|
IND10 | India | 80.56 | 0 |
99
|
99
|
99
|
99
| 49 | 0 |
93
| 0 |
100
|
100
|
ENG | England | 78.95 | 3 | 60 |
93
|
100
|
77
|
94
| 10 | 4 |
95
| 69 |
85
|
FAL | Falklands | 78.92 | 0 |
98
|
94
|
98
|
98
| 10 |
84
|
88
|
90
| 6 | 36 |
FRA2 | France | 77.19 | 63 |
98
|
94
|
97
|
96
|
98
| 59 |
73
|
98
|
90
|
94
|
AUS3 | Australia | 76.93 | 0 | 0 |
90
|
96
|
98
|
84
| 68 | 18 |
100
|
100
|
100
|
NOR | Norway | 76.54 | 26 | 56 | 59 |
100
|
98
|
100
|
84
| 61 |
99
|
84
|
83
|
SPA1 | Spain | 72.44 | 16 |
82
| 66 |
83
|
84
|
84
| 62 | 28 |
78
| 55 | 41 |
AUS4 | Australia | 72.08 | 0 | 20 | 40 |
95
|
86
|
72
| 1 | 0 |
94
|
100
|
98
|
AUS2 | Australia | 68.30 | 4 | 31 | 35 |
84
|
84
| 66 | 20 | 2 |
94
| 55 | 54 |
GRE1 | Greece | 68.12 | 26 |
92
| 45 |
100
|
100
|
100
|
99
|
99
|
100
|
77
|
90
|
IND1 | India | 66.79 | 37 |
98
| 38 |
93
|
100
|
98
|
97
|
98
|
99
|
95
|
95
|
USA | USA | 66.40 | 5 |
77
| 37 |
95
| 37 |
78
| 67 | 13 |
97
|
88
| 68 |
SAF1 | South Africa | 59.05 | 39 | 61 | 68 |
99
|
88
|
97
|
86
| 37 |
97
|
84
|
88
|
BAR | Barbados | 54.46 | 0 | 68 |
90
|
95
|
82
| 7 | 0 | 17 |
87
|
93
|
72
|
IND8 | India | 53.48 | 0 | 45 | 6 |
99
|
76
|
98
| 46 |
81
| 57 |
71
|
87
|
IND7 | India | 50.74 | 1 |
98
| 46 |
99
| 22 |
89
| 0 |
74
| 2 |
90
|
91
|
MAL | Malaysia | 48.31 | 2 | 26 | 51 |
100
|
87
|
87
| 19 | 59 | 61 | 65 | 66 |
IRE | Ireland | 45.69 | 5 | 33 | 38 |
71
|
93
|
94
|
82
| 0 |
93
|
96
| 27 |
JAM | Jamaica | 41.29 | 1 | 56 | 6 |
97
| 62 | 55 | 60 | 57 | 56 | 56 | 51 |
GUY | Guyana | 37.74 | 0 | 0 | 5 |
97
| 31 | 42 | 1 | 5 | 0 | 0 | 0 |
WSA | Western Samoa | 37.21 | 0 | 0 | 39 |
97
| 39 | 49 | 0 | 35 | 26 | 56 | 52 |
IND9 | South Africa | 36.59 | 0 | 10 |
78
|
99
| 40 |
88
| 10 | 9 | 51 | 40 | 63 |
SAF2 | India | 36.59 | 0 | 43 |
90
|
100
| 38 | 57 | 32 | 0 | 3 | 10 | 51 |
IND5 | India | 36.16 | 0 | 1 | 50 |
95
|
80
|
79
| 7 | 47 | 23 | 23 | 4 |
BAN | Bangladesh | 35.71 | 0 |
98
|
95
|
99
| 10 | 14 | 65 | 3 | 8 | 0 | 0 |
ZIM | Zimbabwe | 35.16 | 0 |
100
| 2 |
100
| 0 | 0 | 0 | 42 | 1 | 48 | 22 |
IND3 | India | 33.91 | 0 | 4 | 50 |
100
| 48 |
86
| 0 | 54 | 8 | 4 | 12 |
STK | St. Kitts | 32.75 | 0 | 2 | 0 |
81
|
76
| 49 | 2 | 49 | 0 | 1 | 2 |
GHA | Ghana | 32.42 | 0 |
90
|
100
|
100
| 5 | 21 | 2 | 6 | 1 | 22 | 8 |
PER | Peru | 31.66 | 0 | 64 | 0 |
90
| 50 | 34 | 1 | 9 | 3 | 1 | 1 |
MAU | Mauritius | 30.05 | 0 | 2 | 28 |
96
| 5 |
93
| 5 | 1 | 1 | 18 | 14 |
GRN | Grenada | 29.26 | 0 | 1 |
84
|
100
| 19 |
84
| 10 | 6 | 0 | 13 | 3 |
IND4 | India | 29.20 | 0 |
73
|
96
|
99
|
81
| 27 | 1 | 0 | 6 |
90
| 69 |
IND2 | India | 27.11 | 0 | 0 | 0 |
91
| 0 | 49 | 4 | 4 | 0 | 4 | 2 |
SOL | Solomon Is | 25.26 | 0 | 8 | 0 |
74
| 0 | 0 | 0 | 0 | 0 | 0 | 2 |
GHA2 | Ghana | 19.70 | 0 | 0 | 0 |
100
| 59 | 43 | 1 |
80
| 37 | 54 | 60 |
AUS1 | Australia | 19.66 | 0 | 60 |
73
| 17 | 48 | 39 | 18 | 0 | 47 | 29 | 41 |
IND6 | India | 17.27 | 0 | 0 | 3 |
97
| 13 | 19 | 20 | 15 | 0 | 1 | 0 |
EGY | Egypt | 16.16 | 0 | 0 | 25 |
86
| 3 | 30 | 0 | 3 | 0 | 3 | 17 |
BEL | Belize | 13.35 | 0 | 0 | 2 |
98
| 42 | 40 | 0 | 20 | 0 | 2 | 10 |
TON | Tonga | 10.16 | 0 | 26 | 44 |
96
| 6 | 20 | 0 | 0 | 0 | 0 | 46 |
NICE9 care process assessment | Correlated? | Correlation coefficient | z statistic | p value |
---|---|---|---|---|
BMI
| Yes | 0.357 | 2.421 | 0.015 |
Smoking
| No | 0.282 | 1.877 | 0.061 |
BP
| No | -0.081 | 0.528 | 0.598 |
Cholesterol
| Yes | 0.376 | 2.564 | 0.01 |
Creatinine
| Yes | 0.343 | 2.314 | 0.021 |
Microalbuminuria
| Yes | 0.493 | 3.496 | <0.001 |
Urine protein dipstix
| No | 0.069 | 0.448 | 0.654 |
HbA1c
| Yes | 0.713 | 5.789 | <0.001 |
Eye exam
| Yes | 0.491 | 3.484 | <0.001 |
Foot exam
| Yes | 0.453 | 3.166 | 0.002 |
Questionnaire study
Questions 1–9
Question | Total complete answers | Mean | Median | Mode | Interquartile range | Min range | Max range | % response >50 | |
---|---|---|---|---|---|---|---|---|---|
1
|
What do you think of the alphabet strategy approach?
| 203 | 83 | 87 | 100 | 77-96 | 2 | 100 | 93 |
2
|
Are you likely to adopt this strategy in your clinical practice?
| 192 | 69 | 80 | 100 | 48-92 | 0 | 100 | 71 |
3
|
Do you think your patients would understand and benefit from the educational potential of this strategy?
| 199 | 73 | 82 | 100 | 56-93 | 0 | 100 | 79 |
4
|
Do you think this will improve the outcome of your practice?
| 191 | 77 | 82 | 100 | 64-95 | 0 | 100 | 85 |
5
|
Do you think this strategy can be applied to your economic background?
| 199 | 57 | 60 | 100 | 33-88 | 0 | 100 | 56 |
6
|
Do you think this strategy needs to be translated into your local language?
| 195 | 78 | 91 | 100 | 78-98 | 0 | 100 | 84 |
7
|
Do you think the English version would be more useful in your clinics?
| 195 | 42 | 40 | 0 | 5-79 | 0 | 100 | 36 |
8
|
What do you think of the diabetes care plan?
| 201 | 83 | 87 | 100 | 76-97 | 5 | 100 | 92 |
Question 10–12
Question | Yes | No | Total respondents | % respondents answering yes | |
---|---|---|---|---|---|
10
| Do you think this strategy is practical? | 179 | 18 | 197 | 91% |
11
| Do you think this strategy is evidence based? | 176 | 4 | 180 | 98% |
Summary of responses to question 13
General comments
How could this strategy be implemented?
Implementation of the alphabet strategy in a non-high income country
Care process recording | % Before implementation | % After implementation | p value | |
---|---|---|---|---|
A
| Body Mass Index | 99 | 99 | NS |
Smoking status | 99 | 99 | NS | |
Smoking cessation | 100 | 100 | NS | |
B
| Blood pressure | 99 | 99 | NS |
C
| Total cholesterol | 60 | 99 | <0.001 |
Lipid profile | 10 | 64 | <0.001 | |
Creatinine | 5 | 49 | <0.001 | |
Proteinuria | 48 | 93 | <0.001 | |
D
| Fasting and postprandial glucose | 41 | 97 | <0.001 |
E
| Eye examination | 98 | 100 | NS |
F
| Feet examination | 95 | 100 | NS |
G
| Aspirin therapy | 6 | 71 | <0.001 |
ACEI/ARB therapy | 7 | 57 | <0.001 | |
Statin therapy | 5 | 38 | <0.001 | |
Aspirin + ACEI/ARB + Statin | 2 | 20 | <0.001 | |
QOF score
| 45 | 61 | <0.001 |
Discussion
Pateint-centred, public health driven and professional inspired - patient-safe, meeting the needs of the community with emphasis on preventionOutcome-based - real health improvements base on clear and measurable outcomesEvidence-based - based on clinical research and informed by local clinical auditTeam-delivered - multidisciplinary, professionally inspired and fit for purposeIntegrated - across all healthcare services, and related sectors and agencies